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Food Premise Notification Form

O. Reg. 493/17: FOOD PREMISES under Health Protection and Promotion Act, R.S.O. 1990, c. H.7. A person who gives notice of an intention to commence to operate a food premise to the medical officer of health under subsection 16 (2) of the Act shall include his or her name, contact information and the location of the food premise in the notice.

Documentation must be provided to the health unit a minimum of 14 days prior to proposed opening.



This Notification Form is to notify the Haliburton, Kawartha, Pine Ridge District Health Unit of:
Will food be sold online?


Premise Information:

Is mailing address the same as site address?
Event/Market Layout:
Water Supply:
Franchise Business (20 or more locations in Ontario):


Owner Information:

Operator Information (check yes if same as Owner Information):

Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif


Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif


Operation Information:

Operation Information

Select all days of the week the premises is open and list hours of operation:

Type of Premise(s):
Services (check all that apply)
Type of Food:
Type of food preparation processes involved:

Please contact the health unit to discuss the legal requirements, review plans and/or conduct a pre-operational assessment prior to the proposed event.

Any personal and personal health information that you may provide on this form is collected under the authority of relevant legislation including: the Health Protection and Promotion Act, as amended, the Regulated Health Professions Act, the Immunization of School Pupils Act, and the Personal Health Information Protection Act. This information will be used for assessment, management, treatment, and reporting purposes. Your information may be shared within the Health Unit as required by legislation. For information about the collection, use and disclosure of your information, please refer to the Health Unit website at or contact the Medical Officer of Health, 200 Rose Glen Road, Port Hope, Ontario, L1A 3V6 or 1-866-888-4577.


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